Villa Maria

In the surveyor’s words

From the most serious findings on record at Villa Maria, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 20, 2021

  The facility reported a census of 44 residents. Based on observation and interview, the facility failed to prepare and serve food under sanitary conditions, for the residents of the facility. Findings included: - On 04/13/2021 at 11:07 AM, an initial tour of the kitchen with Dietary Staff (DS) BB, revealed seven frying pans with a brown substance and irregular cooking surfaces, which made them unsanitizable. On 04/13/2021 at 11:07 AM, DS BB verified the above and stated the seven frying pans were not the ones provided by the facility. He explained that the facility cooks brought in these seven personal frying pans from home to cook for the residents. He agreed the pans all had irregular cooking surfaces, and brown debris inside which came into direct contact with the food cooked in them. […]

• No harm, potential for more than minimal, widespreadF814Apr 20, 2021

  The facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included: - On 04/19/21 at 11:40 AM, during a Kitchen tour with Dietary Staff (DS) BB, revealed the lack of a trash can adjacent to the hand washing sink in the food preparation area. An open barrel located approximately 10 feet away from the handwashing sink sat next to the bread rack. The open barrel had paper towels overflowing from the top of the barrel. On 04/19/21 at 11:40 AM, DS BB verified the above findings. He reported the kitchen staff used the barrel to dispose of the paper towels used to dry their hands after washing them. […]

• No harm, potential for more than minimal, widespreadF880Apr 20, 2021

  The facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to follow the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prevent transmission of the pandemic COVID-19 virus. The facility failed to ensure staff were answering screening questions appropriately at the beginning of the shift, failed to quarantine residents when a staff member tested positive for COVID-19 that previously worked two shifts with respiratory symptoms, allowed the facility staff to continue to wear cloth or surgical masks while the facility was in outbreak status (the occurrence of one or more resident and/or staff that test positive for COVID-19), and failed to have a policy in… […]

• No harm, potential for more than minimal, patternF636Sep 9, 2026

  Based on interview and record review the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed within the required 14 calendar days for the following five residents: Resident (R)10, R41, R22, R18, and R27 Findings included:- Review of the Minimum Data Set (MDS) assessment information in the Electronic Health Record revealed concerns regarding the lack of completed comprehensive MDS assessments for residents as follows: R10's 04/15/2026 Admission MDS was marked as In Progress (almost 5 months). R41's 05/04/2026 Admission MDS was marked as In Progress (over 4 months). R22's Annual MDS with an Assessment Reference Date (ARD) date of 06/24/2026, completed on 06/29/2026, and locked [to indicate completed] on 08/20/2026 (almost 2 months). […]

• No harm, potential for more than minimal, patternF640Sep 9, 2026

  Based on interview and record review the facility failed to transmit five resident's Minimum Data Set (MDS) assessments, within the CMS required timeframe. [Resident (R)10, R41, R22, R18, and R27] Findings included:- Review of the Minimum Data Set (MDS) assessment information in the Electronic Health Record revealed concerns regarding the lack of timely submission of MDS information for residents as follows: R10's 04/15/2026 Admission MDS was marked as In Progress and noted an ARD [Assessment Reference Date]: 4/22/2026 140 days overdue.R10's admission MDS lacked evidence of completion and submission (almost 5 months later). R41 admitted on [DATE] and discharged on 05/15/2026. […]